MITCHELL COMMUNITY SCHOLARSHIP FUND Application #

Instructions: This application is designed for you to type your answers in on the computer and then print out your
finalized forms.

This form must be returned by March 1 in to the Mitchell High School Office. If for some reason any of the forms
cannot be filled out and turned in by this date, see your counselor. Please submit a transcript with your
application. Once you have turned in this application, a copy will be made and saved.

Application Data

Name:
Last First Middle Initial

Permanent Address:
Street Address

City State Zip Code

Telephone:

Name of Parent or Guardian:

Certification

All of the information in this application is true and complete to the best of our knowledge. Misinformation of
falsification can lead to the revocation of any or all of your scholarship. We realize this form must be complete and
turned in by the date shown at the top, when it will become the property of the Mitchell Community Scholarship
Foundation. We also realize there will be at least a 100 point deduction for failing to completely comply with the
directives on this form. We acknowledge the amount of the scholarship awarded will be determined by points
received for this application and the number of years I have been enrolled as a regular full-time student in the
Mitchell Public or Mitchell Christian system. We also accept that any scholarships received from the foundation
will be paid upon enrollment as a full time student for second semester or upon completion of programs requiring
less than one year.

Applicant Signature: Date:

Parent or Guardian Signature(s):

Date:
Date:
Do you give permission to the Mitchell Community Scholarship Foundation to pass your application to
other organizations for scholarships consideration:
YES NO

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MITCHELL COMMUNITY SCHOLARSHIP FUND Application #

Post-Secondary Data

Name of college/technical school for which scholarship is requested:

(or schools you are considering if you are undecided at this point)

Please place an X in the box at left that best describes your post-high school plans

I plan on attending a non-4 year institution such as a 2-year program at MTI

I plan on attending a 4-year institution

Please summarize your planned field of post high school study:

What is your anticipated date of graduation from your post high school program?

Month Year

What are the projected costs to complete your education?

How do you plan on financing your education?

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Academic Data

What is your cumulative grade point as of the end of the first semester of your senior year?

What are your ACT scores?

English Math Science Rdg Composite

What was your SAT composite?

Verbal Math

Your class rank currently is out of .

How many semesters have you spent as a regular enrolled full-time student in the Mitchell or Mitchell
Christian High School System?

Please list the courses you have taken as a junior and senior that will have helped prepare you for the
future.

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High School Involvement

Activities Grades Participating Special Honors

th th th th
9 10 11 12 (Such as offices or awards)
Annual Staff
Band
Baseball
Basketball
Cheerleading
Chorus
Class Office
Cross Country
Debate
Drama
FBLA
FFA
FCCLA
Football
Golf
Gymnastics
Hockey
Music Contest
National Honor Society
Newspaper Staff
Jazz Band
Quiz Bowl
Soccer
Softball
Spanish Club
Speech Contest
Stage Band
Student Council
Swim Team
Show Choir
Track
Volleyball
Wrestling
Please list any others below

*Note- World of Work activities do not count in this category.

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Community Involvement

Please list all of the community, civic, and church activities you have voluntarily participated in during the
past four years (examples include: 4-H, scouts, politics, Sunday school, volunteer work of any kind, etc.)
Please give some indication of the type of activity. World of Work activities do not count in this category.

9th Grade
Non-School Activity Nature of Involvement








10th Grade
Non-School Activity Nature of Involvement








11th Grade
Non-School Activity Nature of Involvement








12th Grade
Non-School Activity Nature of Involvement

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Work Experience

In the appropriate cell below list and describe your work experience during the past four years. Indicate
dates of employment and approximate hours worked per week. (Do not differentiate between payment
and non-payment for these positions. Working on the family farm or business still counts as working.)

Hours per
Employer Position Dates (from/to)
week

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

From Mth/Yr To Mth/Yr

Summarize briefly why you worked at the above positions.

Do you plan on working this coming summer?

YES NO
Please Explain:

Do you plan on working at any time during the school year or the summer while you
are a college student? YES NO

Please Explain:

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Aspirations, Goals, and Citizenship

Please describe your educational and career objectives. Include both short and long term goals. To
keep this page anonymous, please DO NOT use your own name or any other information that could link
this writing to you (e.g. parents names, being homecoming king or queen, etc.)

Please summarize how you feel school personnel and community members would describe your
citizenship, attitude, respectfulness, and overall behavior. Try to give examples to support general
statements whenever possible.

Please summarize your involvement in life by listing or describing 3 activities or organizations, in which
you have been a part, that are indicators of your citizenship qualities.

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Special Consideration/Citizenship

Please describe any family or personal circumstances you feel warrant special attention (for example:
financial status, illness, or handicap in the family, etc.).

Citizenship

Have you been suspended for misconduct during your high school career? Please explain.

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MITCHELL COMMUNITY SCHOLARSHIP FUND Application #
On the next page is some information that is supplied by the school office. If there is any of that data that
deserves an explanation please respond here (e.g. you have been absent for more than ten days, etc.).

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Citizenship

This part is to be filled out by the high school counseling office. Print it out, take it to a high
school secretary and nicely ask for assistance in completing the below section.

What is the number of days that the student has been absent from school?
th th th th
9 10 11 12

How many times during high school has the student been tardy?
th th th th
9 10 11 12

**Mitchell Christian Students only**

How many times during the past two years has the student been on suspension?

In school Out of School

**Mitchell High School Students only**

Please list your Saturday School Points.
th th th th
9 10 11 12

How many semesters has this applicant been a regular enrolled full-time student in the Mitchell Public or
Mitchell Christian system?

Date:
High School Secretary

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